Disease Behaviour Classification: A pragmatic model for predicting outcomes in Interstitial Lung Disease

BACKGROUND AND OBJECTIVE

The interstitial lung diseases (ILD) are a heterogenous group of disorders with similar clinical presentation, but widely varying prognoses. The use of a pragmatic disease behaviour classification (DBC), first proposed in international guidelines in 2013, categorises diseases into five behavioural classes based on their predicted clinical course. This study aimed to determine the prognostic utility of the DBC in an ILD cohort.

METHODS

Consecutive patients presented at the weekly multidisciplinary meeting (MDM) of a specialist ILD centre were included. MDM consensus was obtained for diagnosis and DBC category (1-5). Baseline and serial clinical and physiological data were collected over the study period (median 3.9 years, range 0-5.4 years). The relationship between DBC and prognostic outcomes was explored.

RESULTS

137 ILD patients, [64 (47%) female] were included with mean age 67.0 ± 1.1 years, baseline FVC% 72.7 ± 1.7, and baseline DLco% 57.8 ± 1.6%. Patients were stratified into DBC by consensus at MDM: DBC1 n = 0 (0%), DBC2 n = 16 (12%), DBC3 n = 10 (7.3%), DBC4 n = 55 (40%), and DBC5 n = 56 (41%). On univariable Cox regression, increasing DBC class was associated with poorer progression-free survival (HR 1.6, 95% CI 1.2-2.0, p < 0.001). On multivariable Cox regression, DBC remained predictive of PFS when combined with age and gender (HR 1.4, 95% CI 1.1-1.9, p = 0.011), baseline FVC% (HR 1.5, 95% CI 1.1-1.8, p = 0.003) and ILD diagnosis (HR 1.6, 95% CI 1.2-2.2, p < 0.0001).

CONCLUSION

DBC as determined at ILD multidisciplinary meeting may be a useful prognostic tool for the management of ILD patients.

COVID-19 and collective trauma: Implementing a trauma-informed model of care for post-COVID patients

AIM

To describe the implementation of a trauma-informed model of care in the Post COVID Respiratory Clinic of a large tertiary referral centre in NSW.

DESIGN

Discussion paper.

DATA SOURCES

Evidence gathered from a literature search (2008-2022) was used to develop a framework for management of patients presenting to this Post COVID Respiratory Clinic. This paper outlines the personal reflections of the clinic staff as they developed and implemented this framework. Ethical approval was obtained to report the data collected from patient reviews.

DISCUSSION

The literature highlights the high prevalence of trauma in patients following COVID-19 infection, as well as the larger population both during and after the pandemic. This experience of trauma was observed in patients seen within the clinic, indicating a need for specialized care. In response, a trauma-informed model of care was implemented.

CONCLUSION

Reconceptualizing COVID-19 as a 'collective trauma' can help healthcare workers understand the needs of post-COVID patients and enable them to respond empathetically. A trauma-informed model is complementary to this cohort as it specifically addresses vulnerable populations, many of whom have been further marginalized by the pandemic.

IMPLICATIONS FOR NURSING AND PATIENT CARE

Frontline healthcare workers, particularly nurses, are well positioned to implement trauma-informed care due to their high-level of patient contact. Adequate allocation of resources and investment in staff is essential to ensure such care can be provided.

IMPACT

The COVID-19 pandemic has led to adverse physical and mental health outcomes for many. Trauma-informed care is a way to promote reengagement with the healthcare system in this group. Post COVID patients globally may benefit from this approach, as it aims to build trust and independence.

PATIENT OR PUBLIC CONTRIBUTION

Feedback was sought from a patient representative to ensure this paper adequately reflected the experience of the post-COVID patient.

Establishing CREATE: lessons learned in setting up a training environment for early-career researchers in respiratory medicine

BACKGROUND

The purpose of the National Health and Medical Research Council Centre of Research Excellence in Pulmonary Fibrosis (CRE-PF) is to improve and extend the lives of patients living with pulmonary fibrosis through the development of a comprehensive and integrated program of basic and clinical research and education across Australia. A key objective of the CRE-PF was establishment of a unique national training scheme, CREATE, for early-career researchers (ECRs) in respiratory research. CREATE ECRs are broadly drawn from two main fields of researchers: clinicians and scientists, where clinicians tend to be involved in part-time translational research and scientists are involved in broad scientific research including laboratory or genetic research, health economics or population research.

METHODS

We describe the CREATE Program which, with limited budget and the assistance of key organisations, has provided funding opportunities (scholarships, fellowships, prizes, travel and collaboration grants), professional development (mentoring program, symposia, presentation opportunities and on-line training) and fostered a connected, supportive research community for respiratory ECRs.

RESULTS

The CREATE program has successfully fostered the development of the supported researchers, contributing substantially to the future of pulmonary fibrosis research in Australia. During the life of the program the CRE-PF has offered 10 PhD scholarships and five postdoctoral fellowships, awarded 13 travel grants and three grants to promote collaboration between ECRs from different institutes. A mentoring program has been established and CREATE Symposia have been held in association with key meetings. During COVID-19 restrictions, a series of virtual research meetings has offered 12 CREATE ECRs from seven universities the opportunity to present their research to a national audience. CREATE research-related achievements are impressive, including over 80 first-author publications by ECRs, and many conference presentations. Contributions to the research community, measured by committee membership, is also strong.

CONCLUSIONS

In spite of a very limited budget, wide geographic distribution of participants and the multi-disciplinary nature of the cohort, we have succeeded in providing a unique, supportive academic development environment for CREATE ECRs. Lessons learned in the process of developing this program include the importance of leveraging funding, being flexible, building networks and seeking and responding to ECR input.

Recent trends in pirfenidone and nintedanib use for idiopathic pulmonary fibrosis in Australia

ObjectivesIdiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in people aged ≥50 years. There is currently no cure for IPF, but two medications (pirfenidone and nintedanib) have been shown to slow the functional decline of the lungs. In 2017, these two medications were listed on the Pharmaceutical Benefits Scheme (PBS) for subsidisation in Australia. This study evaluated local trends in the use of these two medications.MethodsPrescription data for this analysis were obtained from the PBS Item Reports for the period May 2017-May 2020. Population data were extracted from the Australian Bureau of Statistics data cubes. A descriptive approach was used to conduct and report the analysis to illustrate trends in the use of these two medications and associated costs.ResultsThere were 44 010 prescriptions processed for the treatment for IPF in the 3-year period. Nintedanib use was higher than pirfenidone use, accounting for 54% of prescriptions. New South Wales accounted for 35% of the total prescriptions but, when standardised against population size, the Australian Capital Territory accounted for the highest proportion of prescriptions (24%). Prescriptions for nintedanib and pirfenidone were associated with a total cost of A$131 377 951 over the period 2017-20.ConclusionThis study provides initial information on prescription rates, practices and expenditure for pirfenidone and nintedanib. In addition, we provide some insight into possible pharmacological and epidemiological trends based on jurisdictional differences. Together, the results from this study provide a platform for future research given the dearth of information on IPF in Australia.What is known about the topic?Data regarding trends in the utilisation of antifibrotics for the treatment of IPF in Australia are currently limited.What does this paper add?This study demonstrated that nintedanib use was slightly higher than pirfenidone use, and that there were variations in jurisdictional prescribing practices. The highest number of prescriptions and costs were attributable to New South Wales but, when standardised against population size, the Australian Capital Territory had the highest number of prescriptions and costs.What are the implications for practitioners?This study provides some insights into the use of pirfenidone and nintedanib, as well as pharmacoepidemiological trends, in Australia, which is useful for economic evaluation and modelling future health expenditure.

Peer Connect Service for people with pulmonary fibrosis in Australia: Participants' experiences and process evaluation

BACKGROUND AND OBJECTIVE

People living with pulmonary fibrosis (PF) report unmet needs for information and support. Lung Foundation Australia (LFA) have developed the Peer Connect Service to facilitate telephone support for people with PF across Australia. This project documented the experiences of participants and the resources required to support the service.

METHODS

Consenting participants took part in semi-structured interviews by telephone. Primary peers (peers who agreed to initiate contact) and secondary peers (eligible patients who sought a peer match) were interviewed. Thematic analysis was undertaken by two independent researchers. Data were collected on the number of matches and contacts required to establish each match.

RESULTS

Interviews were conducted with 32 participants (16 primary peers, 15 secondary peers and 1 who was both), aged from 53 to 89 years with 56% being male. Major themes included the value of shared experiences, providing mutual support and the importance of shared personal characteristics (e.g. gender and hobbies) in allowing information and emotional support needs to be met. Participants saw face-to-face contact with peers as highly desirable whilst acknowledging the practical difficulties. Primary peers were cognizant that their role was not to provide medical advice but to listen and share experiences. In the 12-month period, 60 peer matches were made, each match requiring a minimum of seven staff contacts.

CONCLUSION

The Peer Connect Service provides a unique opportunity for people with PF to share experiences and offer mutual support. This telephone matching model may be useful in providing peer support for individuals with rare diseases who are geographically dispersed.

The prevalence of poor sleep quality and its associated factors in patients with interstitial lung disease: a cross-sectional analysis

Background

Many patients with interstitial lung disease (ILD) experience poor sleep quality, which may contribute to decreased quality of life. Sleep disordered breathing is commonly associated with ILD but there is less information on other factors that may contribute to poor sleep quality.

Methods

We conducted a cross-sectional analysis of 101 patients with a diagnosis of ILD at a pulmonary rehabilitation assessment clinic. We assessed the prevalence of poor sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and performed multivariable logistic regression analysis to determine factors independently associated with poor sleep quality.

Results

Median forced expiratory volume in 1 s was 64% predicted (interquartile range (IQR) 50–77%) and vital capacity was 62% predicted (IQR 48–78%). 67 (66%) out of 101 patients reported poor sleep quality. The median PSQI was 8 units (IQR 4–11 units). There were no significant differences in physical or physiological parameters including age, sex distribution, body mass index or spirometry values between subjects with good sleep quality and those with poor sleep quality (all p>0.1). Multivariable logistic regression showed that depression (p=0.003) and Epworth Sleepiness Scale (p=0.03) were independently associated with poor sleep quality.

Conclusion

Poor sleep quality is common in patients with ILD and is independently associated with increasing symptoms of depression and sleepiness. Routine assessment of sleep quality should be undertaken and interventions targeting depression and coexisting sleep disorders may be required in symptomatic patients to determine if sleep quality and ultimately, health-related quality of life improves as a result.

Poor sleep quality is common in patients with interstitial lung disease and is independently associated with increasing symptoms of depression and sleepinesshttp://bit.ly/2WeQbzw

Liver metastases from transitional cell carcinoma are lipiodol avid

A case of transitional cell carcinoma of the bladder with symptomatic liver metastases is presented. When conventional chemotherapy failed, a lipiodol CT scan demonstrated avid uptake by the tumours, which has implications for targeted cancer therapy.